Patterns of hospital utilization for head and neck cancer care: changing demographics

Abstract

Importance: The care of patients with head and neck cancer (HNCA) is becoming increasingly regionalized to high-volume, more effective centers. However, it remains uncertain whether such care is equally distributed. Increasing our understanding of how HNCA treatment is utilized among different sectors should improve strategy designs aimed at ensuring optimized quality of care.

Objective: To determine which patient- or treatment-associated factors may account for increased regionalization of HNCA care.

Design, setting, and participants: Secondary analysis of all inpatient records of hospital admissions with a primary HNCA diagnosis contained within the Nationwide Inpatient Sample during the calendar years 2000, 2005, and 2010.

Main outcomes and measures: Influence of comorbidities, payer, radiation therapy, and case complexity on regionalization of HNCA care to teaching institutions.

Results: In the years 2000, 2005, and 2010, there were an estimated mean (SE) 28,862 (2067), 33,517 (3080), and 37,354 (4194) inpatient hospital HNCA stays, respectively, in the United States. Over time, the respective Charlson comorbidity index (CCI) scores (4.4 and 4.0) and Van Walraven scores (10.0 and 8.9) for nonteaching and teaching institutions were increasingly higher (P < .001). Payer status (private insurance vs Medicaid) did not change for teaching institutions (35.4% vs 33.3%) (P ≥ .63), but the proportion of Medicaid patients did increase over time for nonteaching institutions (10.2% vs 15.8%) (P = .002). Both teaching and nonteaching institutions saw an increase in proportion of prior irradiated cases (7.6% and 4.6% vs 3.4% and 1.9%, respectively) (P ≤ .02). The proportion of major ablative procedures was stable for teaching institutions over time (46.5% vs 43.3%) (P = .57) but decreased for nonteaching institutions (27.2% vs 32.6%) (P = .01). The proportion of flap reconstruction procedures increased over time for teaching institutions (8.6% vs 4.1%) (P < .001) but not for nonteaching institutions (2.7% vs 2.4%) (P = .21).

Conclusions and relevance: Despite the demonstrated link between excellence and outcomes and specialized resource-intensive care, the regionalization of head and neck oncologic treatment is becoming increasingly divergent, and the neediest, sickest patient groups are receiving less than optimal care.